Basic Information
| Provider Information | |||||||||
| NPI: | 1831459890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOULDER | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | D | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 WISHARD BLVD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462022872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179628893 | ||||||||
| FaxNumber: | 3179626722 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 WISHARD BLVD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462022872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179628893 | ||||||||
| FaxNumber: | 3179626722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2012 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01075524A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201093200 | 05 | IN | MEDICAID |